Anticipated Impacts on Veteran's Healthcare: Currently, VHA is the only system where data on Surgical Care Improvement Program (SCIP) performance measures are collected with their targeted outcomes. This study will assess the current state of surgical care performance measurement and will guide future refinements in surgical care quality assessment, and ultimately more informed decision making for preventing adverse surgical outcomes. This will not only improve surgical care, but can eventually lead to reduction in cost to VHA related to adverse outcomes. Project Background: SCIP, a national collaborative to improve surgical care, began in 2005. VHA is one of 34 partners in the project and began tracking SCIP performance through the External Peer Review Program (EPRP) in 2005. The goal of SCIP is to reduce surgical complications by 25% by 2010. While these measures are intended to reduce surgical complications, they are also used as criteria for physician incentive pay as well as hospital quality measurement. Few studies, including our own, have shown associations between individual SCIP performance measures and the adverse surgical outcomes they are intended to prevent, making it unclear as to whether they should be used as the measures of surgical or hospital quality. Our previous study examined the single SCIP measure available in 2006, providing a snapshot of performance and outcomes. There are currently three SCIP topics modules tracked by VA: 1) Infection (6 measures), 2) Venous Thromboembolus (2 measures), and 3) Cardiac Prevention (1 measure). We propose examining the association between the process measures with the adverse surgical outcomes they target. This will provide a more complex, comprehensive assessment of the current state of surgical care performance measurement in VHA. Project Objectives: The objectives of this project are: 1)To determine the factors associated with adherence to SCIP performance at the patient, hospital and system level. 2)To examine the association between SCIP performance measures and adverse surgical outcomes on both a patient and facility level. 3)To analyze trends in surgical complications and SCIP adherence since the inception of the SCIP program in 2005. Project Methods: We propose a cohort study of all elective surgeries accrued in the VA External Peer Review Program SCIP module, with corresponding information in VASQIP from 2005- 2009. Univariate statistics will be used to describe the population, while bivariate statistics will be used to determine unadjusted associations. Composite measures of adherence for each topic will be constructed for each patient. Multivariable logistic regression will be used to examine SCIP measures as predictors of adverse surgical outcomes, with generalized estimating equations to account for clustering within facilities.